UNIVERSITY OF WISCONSIN-STOUT
Application for Employment
Please complete each section of this application accurately and legibly using black or blue ink.
Incomplete applications may be returned and possibly disqualify you from further consideration.
PERSONAL INFORMATION
Today’s Date:
Name
Last
First
Home Telephone (
Middle
Address
Business Telephone (
Street
City
State
Have you ever worked for the State of Wisconsin?
If so, where:
No
Permanent
Dates
Yes
)
Email Address:_________________________
_______________________________________
Dates:
Have you ever worked at UW-Stout?
If yes:
Yes
Zip
)
Date Available for Work:
No
Temporary
Student
Department:
Do you possess a valid driver’s license or are you able to obtain one?
Yes
No
EDUCATION & TRAINING
School
Name and Location
Course of Study
# of Years
Completed
Graduate?
Yes No
Degree
High School
Vocational/Technical
College and/or
Graduate
SKILLS & TRAINING
Typing/keyboarding skills:
Yes
No
Personal computer experience including software programs you
are proficient in:
Describe any other Education, Training or Skills:
List equipment, machinery or motorized vehicles you can
operate:
Employer
WORK EXPERIENCE (begin with your present or most recent employer)
If necessary, attach additional sheets using the format below to provide employment data.
Your Title
Dates of Employment Starting Wage $
Full-time
From:
Part-time
To:
Ending Wage $
Temporary
Address
Duties
Reason for Leaving:
Telephone Number
Work Reference (name & phone number):
Relationship:
Employer
Address
Your Title
Dates of Employment From:
To:
Duties
Full-time
Part-time
Temporary
Starting Wage $
Ending Wage $
Work Reference (name & phone number):
Relationship:
Address
Co-worker
Reason for Leaving:
Telephone Number
Employer
Supervisor
Your Title
Dates of Employment –
From:
To:
Duties
Telephone Number
Full-time
Part-time
Temporary
Supervisor
Co-worker
Starting Wage $
Ending Wage $
Reason for Leaving:
Work Reference (name & phone number):
Relationship:
Supervisor
Co-worker
May we conduct a personal background check including contact of your references named above, and review other records as may
be required for some positions?
Yes
No
If not, why?
It is the policy of UW-Stout to provide reasonable accommodation for qualified individuals who are employees or applicants for
employment. If you need assistance or accommodation for the application process because of a disability, please contact the
Human Resources Office. Employment opportunities will not be denied to anyone because of the need to make reasonable
accommodations for an individual’s disability.
I UNDERSTAND THAT ANY FALSE INFORMATION OR SIGNIFICANT OMISSIONS MAY DISQUALIFY ME FROM
FURTHER CONSIDERATION AND MAY BE JUSTIFICATION FOR MY DISMISSAL FROM EMPLOYMENT, IF
DISCOVERED AT A LATER DATE. I CERTIFY THAT ALL THE INFORMATION ON THIS APPLICATION IS TRUE
AND CORRECT IN EVERY RESPECT.
Signature: ______________________________________________
Date: __________________________________________
The safety and well being of all members of our campus community is very important at the University of Wisconsin-Stout. A
copy of our annual security report may be found at the following website: http://www.uwstout.edu/hs/health-safety-reports.cfm
UW-Stout Human Resources  203 Admin. Bldg.  712 S. Broadway  Menomonie  WI  54751  (715) 232-2438